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A client is experiencing occasional feelings of sadness due to the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors?
- A. The client's behaviors demonstrate mental illness in the form of depression.
- B. The client's behaviors are extensive, indicating the presence of mental illness.
- C. The client's behaviors are not congruent with cultural norms.
- D. The client's behaviors demonstrate no functional impairment, indicating no mental illness.
Correct Answer: D
Rationale: In this scenario, the nurse should interpret the client's behaviors as not indicative of mental illness. The client is experiencing normal feelings of sadness following the loss of a pet, and the fact that the client's appetite, sleep patterns, and daily routine remain unchanged suggests no functional impairment. It is essential to recognize that experiencing occasional feelings of sadness in response to a significant life event, such as the death of a pet, does not necessarily signify mental illness, especially when there is no significant impairment in daily functioning. Choices A, B, and C are incorrect because they incorrectly suggest that the client's behaviors indicate mental illness, which is not the case in this context.
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During an intake assessment, a healthcare professional asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the healthcare professional's best response?
- A. It's just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isn't imperative that we complete this section.
Correct Answer: C
Rationale: The healthcare professional should educate the client on the negative effects of excessive stress on medical conditions. Understanding the interconnectedness of physical and mental health is crucial for providing holistic care. Choice A is incorrect because it doesn't address the importance of psychosocial aspects. Choice B is wrong as it doesn't provide relevant information about the impact of psychological factors on health. Choice D is incorrect because skipping questions would lead to an incomplete assessment, potentially missing crucial information affecting the client's overall health outcomes.
When assessing a patient with generalized anxiety disorder (GAD), which symptom would a nurse most likely observe?
- A. Flashbacks
- B. Excessive worry
- C. Hallucinations
- D. Compulsive behaviors
Correct Answer: B
Rationale: Excessive worry is a primary characteristic of generalized anxiety disorder (GAD). Patients with GAD experience persistent and excessive worry about various aspects of their lives, often anticipating disaster or catastrophic outcomes. This worry is difficult to control and can be accompanied by physical symptoms like restlessness, fatigue, irritability, muscle tension, and difficulty concentrating. Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), hallucinations are more typical of psychotic disorders, and compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD). Therefore, when assessing a patient with GAD, a nurse would most likely observe excessive worry.
A healthcare professional is assessing a client with obsessive-compulsive disorder (OCD). Which of the following findings should the professional expect? Select one that does not apply.
- A. Recurrent, intrusive thoughts
- B. Compulsive behaviors
- C. Delusions of grandeur
- D. Avoidance of situations that trigger obsessions
Correct Answer: C
Rationale: Obsessive-compulsive disorder (OCD) is characterized by recurrent, intrusive thoughts (obsessions), compulsive behaviors, and avoidance of situations that trigger obsessions. Delusions of grandeur, which involve inflated beliefs about one's own importance or abilities, are not typically associated with OCD. Therefore, the presence of delusions of grandeur would not be an expected finding in a client with OCD. Choices A, B, and D are all typical features of OCD and would be expected findings during the assessment of a client with this disorder.
When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, 'I don't drink too much!'
Correct Answer: D
Rationale: The nurse should recognize the client's statement 'I don't drink too much!' as the use of the defense mechanism of denial. This response indicates the client's refusal to acknowledge the reality of excessive alcohol consumption, which is a key characteristic of denial. By denying the problem, the client avoids facing the negative consequences and feelings associated with their alcohol abuse. Choices A, B, and C do not exhibit denial but rather represent different defense mechanisms. Hiding liquor bottles in a closet might indicate the defense mechanism of concealment, yelling at their son for slouching in his chair could reflect displacement, and burning dinner on purpose might suggest passive-aggressive behavior.
Which client statement should alert a nurse that a client may be responding maladaptively to stress?
- A. I've found that avoiding contact with others helps me cope.
- B. I really enjoy journaling; it's my private time.
- C. I signed up for a yoga class this week.
- D. I made an appointment to meet with a therapist.
Correct Answer: A
Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.